Psychosis

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Psychosis is a generic psychiatric term for a mental state often described as involving a “loss of contact with reality”. Stedman’s Medical Dictionary defines psychosis as “a severe mental disorder, with or without organic damage, characterized by derangement of personality and loss of contact with reality and causing deterioration of normal social functioning.”^[1]

People experiencing a psychotic episode may report hallucinations or delusional beliefs (e.g., grandiose or paranoid delusions), and may exhibit personality changes and disorganized thinking. This is often accompanied by lack of insight into the unusual or bizarre nature of their behaviour, as well as difficulty with social interaction and impairment in carrying out the activities of daily living.

A wide variety of nervous system stressors, both organic and functional, can cause a psychotic reaction. This has led to the belief that psychosis is the ‘fever’ of mental illness—a serious but nonspecific indicator.^[2][3]

However, most people have unusual and reality-distorting experiences at some point in their lives, without being impaired or even distressed by these experiences. For example, many people have experienced visions of some kind, and some have even found inspiration or religious revelation in them.^[4] As a result, it has been argued that psychosis is not fundamentally separate from normal consciousness, but rather, is on a continuum with normal consciousness.^[5] In this view, people who are clinically found to be psychotic, may simply be having particularly intense or distressing experiences (see schizotypy).

In pop culture, the term “psychotic” is often used incorrectly to refer to psychopathy.

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1];Associate Editor(s)-in-Chief: Vindhya BellamKonda, M.B.B.S [2]

The word psychosis was first used by Ernst von Feuchtersleben in 1845^[1] as an alternative to insanity and mania and stems from the Greek psyche (soul) and -osis (diseased or abnormal condition).^[2] The word was used to distinguish disorders which were thought to be disorders of the mind, as opposed to neurosis, which was thought to stem from a disorder of the nervous system.

The division of the major psychoses into manic depressive insanity (now called bipolar disorder) and dementia praecox (now called schizophrenia) was made by Emil Kraepelin, who attempted to create a synthesis of the various mental disorders identified by 19th century psychiatrists, by grouping diseases together based on classification of common symptoms. Kraepelin used the term ‘manic depressive insanity’ to describe the whole spectrum of mood disorders, in a far wider sense than it is usually used today. In Kraepelin’s classification this would include ‘unipolar’ clinical depression, as well as bipolar disorder and other mood disorders such as cyclothymia. These are characterised by problems with mood control and the psychotic episodes appear associated with disturbances in mood, and patients will often have periods of normal functioning between psychotic episodes even without medication. Schizophrenia is characterized by psychotic episodes which appear to be unrelated to disturbances in mood, and most non-medicated patients will show signs of disturbance between psychotic episodes.

During the 1960s and 1970s, psychosis was of particular interest to counterculture critics of mainstream psychiatric practice, who argued that it may simply be another way of constructing reality and is not necessarily a sign of illness. For example, R. D. Laing argued that psychosis is a symbolic way of expressing concerns in situations where such views may be unwelcome or uncomfortable to the recipients. He went on to say that psychosis could be also seen as a transcendental experience with healing and spiritual aspects. Thomas Szasz focused on the social implications of labelling people as psychotic; a label he argues unjustly medicalises different views of reality so such unorthodox people can be controlled by society. Psychoanalysis has a detailed account of psychosis which differs markedly from Psychiatry.

In medical practice today, a descriptive approach to psychosis (and to all mental illness) is used, based on behavioral and clinical observations. This approach is adopted in the standard guide to psychiatric diagnoses employed in the United States, the Diagnostic and Statistical Manual of Mental Disorders (DSM). Since the DSM provides a widely-used standard of reference, the description presented here will largely reflect that point of view.

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Vindhya BellamKonda, M.B.B.S [2] Rim Halaby, M.D. [3]

Psychosis refers to a clinical presentation including one or more of the following abnormalities: delusions, hallucinations, disorganized speech, disorganized motor function, and negative symptoms. The classification of psychosis depends on the level, number, and duration of symptoms. Psychosis can be classified into: abnormalities limited to one feature of psychosis, schizophrenia spectrum, psychosis caused by specific conditions, and other specific schizophrenia spectrum and other psychotic disorders.

Shown below is an algorithm depicting the classification about psychosis.^[1]

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1];Associate Editor(s)-in-Chief: Vindhya BellamKonda, M.B.B.S [2]

Psychosis has been traditionally linked to the neurotransmitter dopamine. In particular, the dopamine hypothesis of psychosis has been influential and states that psychosis results from an over-activity of dopamine function in the brain, particularly in the mesolimbic pathway. The two major sources of evidence given to support this theory are that dopamine-blocking drugs (i.e. anti psychotics) tend to reduce the intensity of psychotic symptoms, and that drugs which boost dopamine activity (such as amphetamine and cocaine) can trigger psychosis in some people (see amphetamine psychosis).^[1] However, increasing evidence in recent times has pointed to a possible dysfunction of the excitory neurotransmitter glutamate, in particular, with the activity of the NMDA receptor. This theory is reinforced by the fact that dissociative NMDA receptor antagonists such as ketamine, PCP and dextromethorphan/dextrorphan (at large overdoses) induce a psychotic state more readily than dopaminergic stimulants, even at “normal” recreational doses. The symptoms of dissociative intoxication are also considered to mirror the symptoms of schizophrenia more closely, including negative psychotic symptoms than amphetamine psychosis. Dissociative induced psychosis happens on a more reliable and predictable basis than amphetamine psychosis, which usually only occurs in cases of overdose, prolonged use or with sleep deprivation, which can independantly produce psychosis. New antipsychotic drugs which act on glutamate and it’s receptors are currently undergoing clinical trials. (See glutamate hypothesis of psychosis)

The connection between dopamine and psychosis is generally believed to be complex. While antipsychotic drugs immediately block dopamine receptors, they usually take a week or two to reduce the symptoms of psychosis. Moreover, newer and equally effective antipsychotic drugs actually block slightly less dopamine in the brain than older drugs whilst also affecting serotonin function, suggesting the ‘dopamine hypothesis’ may be oversimplified.^[2] Soyka and colleagues found no evidence of dopaminergic dysfunction in people with alcohol-induced psychosis^[3] and Zoldan et al. reported moderately successful use of ondansetron, a 5-HT₃ receptor antagonist, in the treatment of levodopa psychosis in Parkinson’s disease patients.^[4]

Psychiatrist David Healy has criticised pharmaceutical companies for promoting simplified biological theories of mental illness that seem to imply the primacy of pharmaceutical treatments while ignoring social and developmental factors which are known to be important influences in the etiology of psychosis.^[5]

Some theories regard many psychotic symptoms to be a problem with the perception of ownership of internally generated thoughts and experiences.^[6] For example, the experience of hearing voices may arise from internally generated speech that is mislabeled by the psychotic person as coming from an external source.

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1];Associate Editor(s)-in-Chief: Vindhya BellamKonda, M.B.B.S [2]

Causes of mental illness are customarily distinguished as “organic” or “functional”. Organic causes are those for which a medical, pathophysiological basis can be found. Functional causes are “the rest”, the psychological causes properly speaking, e.g. anxiety, depression, etc.

Functional causes of psychosis include the following:

• Schizophrenia
• Bipolar disorder (manic depression)
• Severe clinical depression
• Severe psychosocial stress
• Sleep deprivation

A psychotic episode can be significantly affected by mood. For example, people experiencing a psychotic episode in the context of depression may experience persecutory or self-blaming delusions or hallucinations, while people experiencing a psychotic episode in the context of mania may form grandiose delusions.

Stress is known to contribute to and trigger psychotic states. A history of psychologically traumatic events, and the recent experience of a stressful event, can both contribute to the development of psychosis. Short-lived psychosis triggered by stress is known as brief reactive psychosis, and patients may spontaneously recover normal functioning within two weeks.^[1] In some rare cases, individuals may remain in a state of full-blown psychosis for many years, or perhaps have attenuated psychotic symptoms (such as low intensity hallucinations) present at most times.

Sleep deprivation has been linked to psychosis.

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1];Associate Editor(s)-in-Chief: Vindhya BellamKonda, M.B.B.S [2]

Psychosis must be differentiated from, Apparitional experience, delusional disorder, monothematic delusions, Jerusalem syndrome,clinical lycanthropy,soteria, hallucinations in the sane.

• Apparitional experience
• Delusional disorder
• Monothematic delusions
• Jerusalem syndrome
• Clinical Lycanthropy
• Soteria
• Hallucinations in the sane

According to the DSM, psychosis can be a symptom of mental illness, but it is not a mental illness in its own right. For example, people with schizophrenia often experience psychosis, but so can people with bipolar disorder (manic depression), unipolar depression, delirium, or drug withdrawal.^[1][2] People diagnosed with these conditions can also have long periods without psychosis. Conversely, psychosis can occur in people who do not have chronic mental illness (e.g. due to an adverse drug reaction or extreme stress).^[3]

Psychosis should be distinguished from insanity, which is a legal term denoting that a person is not criminally responsible for his or her actions.^[4]

Psychosis should be distinguished from psychopathy, a personality disorder associated with violence, lack of empathy and socially manipulative behavior.^[5] Despite both being colloquially abbreviated “psycho”, psychosis bears little similarity to the core features of psychopathy, particularly with regard to violence, which rarely occurs in psychosis,^[6][7] and distorted perception of reality, which rarely occurs in psychopathy.^[8]

Psychosis should also be distinguished from delirium. A psychotic individual may be able to perform actions that require a high level of intellectual effort in clear consciousness, whereas a delirious individual will have impaired memory and cognitive function.

Psychosis should further be distinguished from neurosyphilis, which presents as hallucinations, delusions, auditory hallucinations, and flat or blunted affect and emotion, poverty of speech (alogia), anhedonia, and lack of motivation.^[9]

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Kiran Singh, M.D. [2]

Risk factors for psychosis include schizotypal personality disorder, borderline personality disorder, and suspiciousness among others.^[1]

• Preexisting personality disorders

• Schizotypal personality disorder

• Borderline personality disorder

• Traits in the psychoticism domain

• Perceptual dysregulation

• Suspiciousness^[1]

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1];Associate Editor(s)-in-Chief: Vindhya BellamKonda, M.B.B.S [2]

Psychosis can prevent people from functioning normally and caring for themselves. If the condition is left untreated, people can sometimes harm themselves or others.

• How well a person does depends on the cause of the psychosis. If the cause can be corrected, the outlook is often good, and treatment with antipsychotic medication may be brief.

• Some chronic conditions, such as schizophrenia, may need life-long treatment with antipsychotic medications to control symptoms.

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